Name

First Name

Last Name

Date of Birth

Medication Name: Semaglutide or Tirzepatide? Other?

Current Weight

Have you experienced any negative side effects?

Any changes in medications, medical/surgical history since your last visit or order? Do you have any upcoming surgeries or procedures?

Do you want to stay on current dose or increase? Our office will contact you if further clarification is needed

Any other information you would like us to know? If this is a pharmacy refill, please provide pharmacy details:

For patients on maintenance, would you like to have recurring invoices sent via email? *This will not charge your card, simply auto-email an invoice*

Please confirm shipping address below if shipping to home ($40) or indicate if shipping to office for pick up (no additional cost)

When was or will be your last dose, and what was the dosage?

Do you need more syringes?

MEDICATION ORDER FORM

***FOR EXISTING PATIENTS ONLY:

PLEASE USE THIS FORM TO ASSIST US IN PLACING YOUR ORDER.

Please note: This form will not automatically place medication orders.

You will be sent an invoice when the order is approved by the provider. This invoice must be paid before we will order your medication from the pharmacy unless other arrangements have been discussed.

Vitality Health & Wellness

604 Government Center Way, Suite 4, Evans, Georgia 30809

(706) 305-4286

Hours

Mon - 09:00 am – 05:00 pm

Tue - 09:00 am – 05:00 pm

Wed - 09:00 am – 12:00 pm

Thu - 09:00 am – 05:00 pm

Fri - 09:00 am – 05:00 pm

Sat - By Appointment

Sun - Closed